2016 HEALTH FACILITY ASSESSMENT FOR REPRODUCTIVE HEALTH COMMODITIES AND SERVICES

Transcription

1 2016 HEALTH FACILITY ASSESSMENT FOR REPRODUCTIVE HEALTH COMMODITIES AND SERVICES

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3 2016 Health Facility Assessment For Reproductive Health Commodities and Services Department of Medical Research (Pyin Oo Lwin Branch) Department of Public Health Department of Medical Services and UNFPA May 2016

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5 Foreword HEALTH FACILITY ASSESSMENT FOR RHCS 2016 Access to family planning is a fundamental human right and is crucial to empowering women and girls to realize their full potential. It is also one of the most cost-effective investments a country can make towards sustainable development. Although Myanmar has given priority to maternal and child health services and considerable investments have been made to improve these services, inadequate health resources at different levels of the health system and the heavy workload of staff are still creating challenges to achieve targets. Limited availability of skilled service providers, essential commodities and logistics management are major concerns in Myanmar. In addition, the weakness of the Logistic Management Information System (LMIS) in terms of its geographic coverage and functioning has led to frequent shortages of essential and life-saving reproductive health (RH) medicines and commodities resulting in an unmet need for potential clients. Since RH services must be of a high quality in all respects, a regular supply of medicines for emergency obstetric care (EmOC) and contraceptives to meet the needs of facilities is crucial. The Ministry of Health and Sports is making efforts to achieve the Sustainable Development Goals (SDGs), especially in reducing maternal mortality and child mortality by providing quality services covering the whole country. In the area of reproductive health, progress has been made in maternal and newborn health and birth spacing with a reduction in maternal mortality and an increase in the contraceptive prevalence rate. To build on accomplishments to date, health systems need to be strengthened and targeted programmes implemented for the most vulnerable populations. In line with the National Health Plan, the Ministry of Health and Sports has been planning and implementing interventions to improve the health status of mothers, newborns and children. Therefore, a Nationwide Health Facility Assessment for RH Commodities and Services was implemented with strong support from the Department of Medical Research (Pyin Oo Lwin Branch) in collaboration with the Maternal and Reproductive Health Division, the Department of Public Health and the Department of Medical Services. Well organized and trained teams actively participated in data collection across the country during May and September As the assessment is a continuation of the 2014 and 2015 assessment activities, this report is a result of a successful third mission. We aim to provide the information and understanding needed to improve the country s Reproductive Health Security. These consecutive assessments over the past three years will make programme managers, donors and policymakers more able to closely monitor the effectiveness, weaknesses, and lessons learnt from past interventions and make reliable projections for future implementations. The current situation on the availability of birth spacing services; life-saving reproductive health medicines; stock-outs; the logistic management system; the availability of skilled staff for reproductive health care services; information and communication facilities; cold chain facilities; and clients satisfaction are provided in this report. Comparisons of some important parameters over the three years are also included. In contrast to previous reports, information from private sector health facilities is included in this report. We would like to thank all concerned persons without whose relentless efforts and dedication this undertaking would not have been successful. In particular, we would like to express our heartfelt thanks to Ms. Janet E. Jackson, UNFPA Representative for Myanmar, for her keen interest and support for this undertaking. Thanks are also due to Dr. Hla Hla Aye (Assistant Representative, UNFPA), Daw Yu Myat Mun (Programme Analyst, UNFPA), Dr. Aung Thu Tun (Programme Specialist, UNFPA) and other staff of UNFPA for their continuous support throughout the implementation process. Dr. Kyaw Zin Thant Director General Department of Medical Research I

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7 Acknowledgements The 2016 Health Facility Assessment for Reproductive Health Commodities and Services is the third survey of its kind over the last three years in Myanmar, covering both public and private health facilities across the entire country. This was an immense task that took several months and was undertaken as a collaborative endeavour together with the Department of Medical Research, the Department of Medical Services and the Department of Public Health with technical support from UNFPA Myanmar Country Office. This assessment was made possible thanks to funding from the UNFPA Supplies Programme, formerly known as GPRHCS. This assessment aims to pinpoint areas to strengthen the health system including the supply chain system in which the Logistics Management Information System has been established to improve family planning/reproductive health commodity security in Myanmar. In order to strategically improve family planning programmes, and to promote resource allocation and enhance programme efficiency to reduce unmet needs for modern methods of contraception, it is essential to ensure that facilities have high quality and equitable family planning and reproductive health commodities, services and the contraceptive choices that women need. The survey also underlines key challenges to strengthen the health system especially in ensuring access to all, irrespective of the level of facility and its location. The survey findings were validated through a dissemination workshop held on 21 December, 2016 and contributed to the Family Planning 2020 core indicators at the consensus review meeting on 19 May UNFPA expresses special gratitude to Dr. Kyaw Oo, formerly the Director of the Department of Medical Research (Upper Myanmar), now the Deputy Director General of the Department of Human Resources for Health, for his valuable support and technical guidance to undertake this survey. UNFPA acknowledges the support of health authorities from each state/region, the Department of Medical Services, the Department of Public Health, and the Maternal and Reproductive Health Division of the Department of Public Health. Our grateful thanks also go to the Department of Medical Research for their leadership, technical support, and managerial and supervisory role in field data collection activities, without which this facility assessment would not have been completed within a very limited time frame. The assistance and support of field enumerators and technical supervisors recruited from the Department of Medical Research (Pyin Oo Lwin Branch) was invaluable. Special thanks are also due to health staff in hard-to-reach areas for their kind arrangements in facilitating local transport to help the survey team complete the survey in a timely manner. Janet E. Jackson UNFPA Representative for Myanmar III

8 Contents Foreword / I Acknowledgements / III List of Tables / VI List of Figures / XI List of Contributors / XII List of Acronyms / XVI Executive summary / XVII Recommendations / XXI A. Commodities security / XXI B. Contraceptive services / XXI C. Logistic and Supply Chain Management System / XXI D. Monitoring and evaluation / XXII E. Waste disposal / XXII F. Methodology for assessments / XXII Part I: Introduction / 1 Background / 1 UNFPA Supplies / 1 Country profile of Myanmar / 1 Rationale / 2 Objective of assessment / 3 General objective / 3 Specific objectives / 3 Research methodology / 3 Study design / 3 Sampling procedure / 3 Questionnaire / 6 Fieldwork/data collection / 6 Data analysis / 7 Ethical considerations / 7 Successes and challenges of the study / 7 Part II: Summary of the national protocols / 9 Maternal and reproductive health in Myanmar / 9 National Health Plan for Maternal and Reproductive Health / 10 Strategic Plan for Reproductive Health / 10 Guidelines and laws which underline the provision of contraceptive and maternal/rh commodities / 11 IV

9 Part III. Findings / 12 Sample health facilities / 12 Section A1. Modern contraceptives offered by primary facilities / 13 Section A2. Modern contraceptives offered by secondary and tertiary facilities / 17 Section B. Availability of Maternal and RH Medicines / 21 Section C. Incidence of no stock-outs of modern contraceptives in the last six months / 25 Section D. Incidence of no stock-outs of modern contraceptives on the day of the survey / 31 Section E. Supply Chain, including cold chain / 41 E1. Responsible person for ordering re-supplies / 41 E2. Quantifying resupplies / 44 E3. Source of supplies / 47 E4. Transportation of supplies / 49 E5. Length of time between order and receipt of supplies / 51 E6. Frequency of resupply / 53 E7. Availability of a cold chain / 55 Section F. Staff training and supervision / 62 Section G. Availability of guidelines, checklists and job aids / 75 Section H. Use of Information and Communication Technology (ICT) / 82 Section I. Waste disposal / 88 Section J. User fees / 89 PART IV. Findings from client s interview / 104 Background characteristics of clients / 104 Clients perception of family planning service provision / 110 Clients appraisal of costs of family planning services / 116 Part V: Summary of findings / 130 Summary of findings about HFs / 130 Summary of findings about clients / 133 Part VI. Conclusions / 134 Part VII. Recommendations / 138 A. Commodities security / 138 B. Contraceptive services / 138 C. Logistics and supply chain management system / 138 D. Monitoring and evaluation / 139 E. Waste disposal / 139 F. Methodology for assessment / 139 V

10 List of Tables Table 1a. Table 1b. Table 1c. Table 1d. Table 1e. Table 2a. Table 2b. Table 2c. Table 2d. Table 2e. Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table 10. Table 11. Table 12. Table 13a. Table 13b. Percentage distribution of primary level HFs providing at least three modern contraceptive methods by type of facility /13 Percentage distribution of primary level HFs providing at least three modern contraceptive methods by state/region /14 Percentage distribution of primary level HFs providing at least three modern contraceptive methods by urban/rural area /15 Percentage distribution of primary level HFs providing at least three modern contraceptive methods by management off facility /15 Percentage distribution of primary level HFs providing at least three modern contraceptive methods by distance from nearest warehouse/source of supply /16 Percentage distribution of secondary and tertiary level HFs providing at least five modern contraceptive methods by type off facility /17 Percentage distribution of secondary and tertiary level HFs providing at least five modern contraceptive methods by state/region /17 Percentage distribution of secondary and tertiary level HFs providing at least five modern contraceptive methods by urban/rural area /19 Percentage distribution of secondary and tertiary level HFs providing at least five modern contraceptive methods by management of facility /19 Percentage distribution of secondary and tertiary level HFs providing at least five modern contraceptive methods by distance from nearest warehouse/source of supply /20 Percentage distribution of HFs with seven (including two essential) life-saving maternal/reproductive health medicines available by type of facility / 21 Percentage distribution of HFs with seven (including two essential) life-saving maternal/reproductive health medicines available by state/region / 22 Percentage distribution of HFs with seven (including two essential) life-saving maternal/reproductive health medicines available by urban/rural area / 23 Percentage distribution of HFs with seven (including two essential) life-saving maternal/reproductive health medicines available by management of facility / 23 Percentage distribution of HFs with seven (including two essential) life-saving maternal/reproductive health medicines available by distance from nearest warehouse/source of supply / 24 Percentage distribution of HFs with no stock-outs of a modern contraceptive method in the last six months by type of facility / 25 Percentage distribution of HFs with no stock-outs of a modern contraceptive method in the last six months by state/region / 26 Percentage distribution of HFs with no stock-outs of a modern contraceptive method in the last six months by urban/rural area / 27 Percentage distribution of HFs with no stock-outs of a modern contraceptive method in the last six months by management of facility / 27 Percentage distribution of HFs with no stock-outs of a modern contraceptive method in the last six months by distance from nearest warehouse/source of supply / 28 No stock-out status in the last six months for each modern contraceptive method by level of HF /29 No stock-out status in the last six months for modern contraceptive methods by HF by state/region /30 VI

11 Table 13c. Common reasons for contraceptive stock-outs in last six months /31 Table 14. Percentage distribution of HFs with no stock-outs of modern contraceptive methods at the time of the survey by type of facility / 31 Table 15. Percentage distribution of HFs with no stock-outs of modern contraceptive methods at the time of the survey by state/region / 32 Table 16. Percentage distribution of HFs with no stock-outs of a modern contraceptive method at the time of the survey by urban/rural area / 33 Table 17. Percentage distribution of HFs with no stock-outs of a modern contraceptive method at the time of the survey by management of facility / 33 Table 18. Percentage distribution of HFs with no stock-outs of a modern contraceptive method at the time of the survey by distance from nearest warehouse/ source of supply / 34 Table 19a. Incidence of no stock-outs of a modern contraceptive method by level of HF /35 Table 19b. Incidence of no stock-outs of a modern contraceptive method by HF by state/region /36 Table 19c. Incidence of no stock-outs of a modern contraceptive by urban and rural HF /37 Table 19d. Incidence of no stock-outs of a modern contraceptive by location of HF /38 Table 19e. Incidence of no stock-outs of a modern contraceptive by travel duration to source of supply /38 Table 19f. Incidence of no stock-outs of a modern contraceptive by means of transport to source of supply /39 Table 19g. Common reasons for contraceptive stock-outs on the day of the survey /39 Table 19h. Level-wise comparison of recent stock-outs for at least one method between 2014, 2015 and 2016 assessments /40 Table 19i. Comparison of method specific stock-outs at the time of assessment between 2014, 2015 and 2016 assessments /41 Table 20. Percentage distribution of HFs with person responsible for ordering medical supplies by type of HF / 41 Table 21. Percentage distribution of HFs with person responsible for ordering medical supplies by state/region / 42 Table 22. Percentage distribution of HFs with person responsible for ordering medical supplies by urban/rural area / 43 Table 23. Percentage distribution of HFs with person responsible for ordering medical supplies by management of facility / 43 Table 24. How resupply is quantified by type of HF / 44 Table 25. How resupply is quantified by state/region / 44 Table 26. How resupply is quantified by urban/rural area / 45 Table 27. How resupply is quantified by management of facility / 45 Table 28. How resupply is quantified by distance to depot from facility / 46 Table 29. Main source of supplies by type of HF / 47 Table 30. Main source of supplies by state/region / 47 Table 31. Main source of supplies by management of facility / 48 Table 32. Main source of supplies by urban/rural area / 48 Table 33. Responsibility for transportation of supplies by type of HF / 49 Table 34. Responsibility for transportation of supplies by state/region / 49 Table 35. Responsibility for transportation of supplies by urban/rural residence / 50 VII

12 Table 36. Responsibility for transportation of supplies by management of facility / 51 Table 37. Estimated length of time between order and receipt of supplies by type of HF / 51 Table 38. Estimated length of time between order and receipt of supplies by state/region / 52 Table 39. Estimated length of time between order and receipt of supplies by urban/rural area / 53 Table 40. Estimated length of time between order and receipt of supplies by management of facility / 53 Table 41. Frequency of resupply by type of HF / 53 Table 42. Frequency of resupply by state/region / 54 Table 43. Frequency of resupply by urban/rural area / 55 Table 44. Frequency of resupply by management of facility / 55 Table 45. Availability of a cold chain system by type of HF / 55 Table 46. Availability of a cold chain system by state/region / 56 Table 47. Availability of a cold chain system by urban/rural area / 57 Table 48. Availability of a cold chain system by management of facility / 57 Table 49. Type of cold chain by state/region / 58 Table 50. Source of power for fridges used for cold chain system by type of HF / 59 Table 51. Source of power for fridges used for cold chain system by state/region / 60 Table 52. Source of power for fridges used for cold chain system by urban/rural area / 61 Table 53. Source of power for fridges used for cold chain by management of facility / 61 Table 54. Percentage of HFs with trained staff to provide FP services and to insert and remove implants / 62 Table 55. Percentage distribution of staff trained to provide FP services and to insert and remove implants by type of HF / 62 Table 56. Percentage distribution of staff trained to provide FP services and to insert and remove implants by states/regions / 63 Table 57. Percentage distribution of staff trained to provide FP services and to insert and remove implants by urban/rural area / 64 Table 58. Percentage distribution of staff trained to provide FP services and to insert and remove implants by management of facility / 65 Table 59. Percentage distribution of the last time staff received training to provide FP services including to insert and remove implants by HF / 65 Table 60. Percentage distribution of the last time staff received training to provide FP services including to insert and remove implants by state/region / 66 Table 61. Percentage distribution of the last time staff received training to provide FP services including to insert and remove implants by urban/rural area / 67 Table 62. Percentage distribution of the last time staff received training to provide FP services including to insert and remove implants by management of facility / 67 Table 63. Percentage distribution of the last time the facility was supervised in the past 12 months by type of HF / 68 Table 64. Percentage distribution of the last time the facility was supervised in the past 12 months by state/region / 68 Table 65. Percentage distribution of the last time the facility was supervised in the past 12 months by urban/rural area / 70 Table 66. Percentage distribution of the last time the facility was supervised in the past 12 months by management of facility / 70 Table 67. Percentage distribution of the frequency of supervisory visits by type of HF / 70 Table 68. Percentage distribution of the frequency of supervisory visits by state/region / 71 Table 69. Percentage distribution of the frequency of supervisory visits by urban/rural area / 72 VIII

13 Table 70. Percentage distribution of the frequency of supervisory visits by management of facility / 72 Table 71. Percentage of HFs by issues included in supervisory visits by type of HF / 72 Table 72. Percentage of HFs with issues included in supervisory visits by state/region / 73 Table 73. Percentage of HFs by issues included in supervisory visits by urban/rural areas / 74 Table 74. Percentage of issues included in supervisory visits by management of facility / 74 Table 75. Percentage of HFs with guidelines, checklists and job aids / 75 Table 76a. Have guidebook for national birth spacing /75 Table 76b. Have checklist for birth spacing /77 Table 76c. Have ANC guidelines (National/WHO) /78 Table 76d. Have checklist/job aid for AN care / 79 Table 76e. Have guidebook for waste disposal / 81 Table 77. Percentage of HFs by type of information and communication technology available / 82 Table 78. Type of information and communication technology available / 82 Table 79. Percentage of HFs by how ICT equipment was acquired / 84 Table 80. Percentage of HFs by main purpose for which ICT is used / 86 Table 81. Percentage distribution of HFs by method of waste disposal / 88 Table 82. Types of user charges / 89 Table 83. Percentage distribution of HFs by issue for which user fee is charged for consultation / 90 Table 84. Percentage distribution of HFs by issue for which user fee is charged for medication / 91 Table 85. Percentage distribution of HFs by issues for which user fee is charged for services provided by a qualified health care provider / 93 Table 86. Percentage distribution of HFs providing modern contraceptive methods / 95 Table 87. Percentage distribution of HFs with any MRH medicine available / 98 Table 88. Percentage distribution of HFs with any modern contraceptive methods in-stock (no stock-outs) in the last six months / 100 Table 89. Percentage distribution of HFs with a modern contraceptive method in-stock (no stock-out) at the time of the survey / 101 Table 90. Sex distribution of clients / 105 Table 91. Age distribution of clients / 105 Table 92. Marital status of clients / 107 Table 93. Percentage distribution of clients by education level / 108 Table 94. Percentage distribution of clients by frequency of visit to HF for FP services / 109 Table 95. Percentage distribution of clients perspective of FP service provider s adherence to technical issues / 110 Table 96. Percentage distribution of clients perspective of FP service organizational aspects / 112 Table 97. Percentage distribution of clients perspectives of interpersonal aspects of FP services / 113 Table 98. Percentage distribution of clients perspective of FP service outcomes / 114 Table 99. Percentage of clients reporting paying for services and average amount paid by type of HF / 116 Table 100. Percentage of clients reporting paying for services and average amount paid by management of facility / 117 Table 101. Percentage of clients reporting paying for services by state/region / 118 IX

14 Table 102. Percentage of clients reporting paying for services and average amount paid by state/region / 119 Table 103. Percentage of clients reporting paying for services by urban/rural area / 120 Table 104. Percentage of clients reporting paying for services and average amount paid by urban/rural area / 120 Table 105. Percentage distribution of clients by mode of transport, distance travelled and cost of transportation / 121 Table 106a. Percentage distribution of clients by mode of transport /122 Table 106b. Percentage distribution of clients by distance from clinic /123 Table 106c. Percentage distribution of clients by cost of clinic visit /124 Table 107. Average time spent by client to visit clinic for FP services / 125 Table 108. Percentage distribution of clients by activities they would have been engaged in during the time spent receiving FP services / 126 Table 109. Percentage distribution of clients by person indicated to have performed activities on their behalf while they were receiving FP services / 127 Table 110. Average amount paid to person who performed activities on behalf of client while client was receiving FP services / 128 Table 111. Percentage distribution of clients by source of funds used to pay for FP services / 128 Table 112. Average amount paid by each source by background characteristics of client / 129 X

15 List of Figures Figure 1. Distance to nearest medical depot from HF by state/region /13 Figure 2. Primary level HFs providing three modern contraceptives /15 Figure 3. Percentage of HFs providing five modern contraceptive methods by level of HF /18 Figure 4. Percentage of HFs which could provide seven life-saving RH medicines by state/region /23 Figure 5. Percentage of HFs with no contraceptive stock-outs in last six months by state/region /27 Figure 6. Percentage of HFs with no recent stock-outs of a modern contraceptive by state/region /33 Figure 7. HFs which have no recent stock-outs of each modern contraceptive across states/regions /37 Figure 8. Comparison of recent no-stock-outs by level of HF over 2014, 2015 and 2016 assessments /40 Figure 9. Percentage distribution of HFs with four major categories responsible for ordering medical supplies by state/region /43 Figure 10. Percentage of HFs which have a cold chain system by state/region /57 Figure 11. Percentage of HFs which have trained staff for birth spacing and to remove and insert implants /64 Figure 12. Percentage of HFs where staff received training more than one year ago /67 Figure 13. Percentage of HFs which had never received supervision for RH matters /69 Figure 14. Percentage of HFs supervised for different issues /74 Figure 15. Percentage of HFs which had received a government supply of ICT devices by state/region /85 Figure 16. A comparison of the availability of RH Medicine from 2015 to 2016 /103 Figure 17. Percentage of HFs where fees are charged for services /117 XI

16 List of Contributors Investigators Principal Investigator Dr. Kyaw Oo Deputy Director General DHRH Co-investigators Dr. Hla Mya Thwe Einda Director (Maternal & Reproductive Health Division) DOPH Dr. Moe Kyaw Myint Deputy Director (Health System Research) DMR(POLB) Dr. Kyaw Thu Soe Research Officer (Health System Research) DMR(POLB) Technical coordinators Dr. Hla Hla Aye Assistant Representative UNFPA Daw Yu Myat Mum Programme Analyst (RH/ARH) UNFPA Dr. Aung Thu Tun Programme Specialist (RHCS) UNFPA Assessment Team Field Technical Supervisors 1. Dr. Kyaw Oo Deputy Director General DHRH 2. Dr. Moe Kyaw Myint Deputy Director (Health System Research) DMR (POLB) 3. Dr. Nyein Nyein Thaung Research Officer (Pathology) DMR (POLB) 4. U Than Myat Soe Research Officer (Medical Entomology DMR (POLB) 5. Dr. Thae Maung Maung Research Officer (Medical Statistics) DMR 6. Dr. Thet Oo Wai Research Officer (Medical Statistics) DMR (POLB) 7. Dr. Yadanar Aung Research Officer (Health System Research) DMR (POLB) 8. Daw Phyu Phyu Wynn Research Scientists (Parasitology Division) DMR (POLB) 9. Dr. Kay Thwe Thwe Maung Research Officer (Medical Statistics) DMR (POLB) 10. Dr. Su Su Lynn Research Officer (Medical Statistics) DMR (POLB) 11. Dr. Phyu Phyu Thin Zaw Research Scientists (Epidemiology) DMR (POLB) 12. Dr. Khin Moe Aung Research Scientists (Pathology) DMR (POLB) 13. Dr. Aung Thu Research Officer (Medical Statistics) DMR (POLB) 14. Dr. Kyaw Thu Soe Research Officer (Health System Research) DMR (POLB) Local Field Supervisors 1. Dr. Than Than Myint Deputy Director General (Department of Medical services) Mandalay Region Dr. Win Naing Regional Public Health Director Mandalay Region Dr. Yu Yu Wai Deputy Director Mandalay Region 2. Dr. Than Lwin Htun Regional Public Health Director Sagaing Region Dr. Aye Nyein Regional Medical Service Director Sagaing Region U Saw Hlaing THA, Regional Public Health Department Sagaing Region 3. Dr. Maung Maung Zin State Medical Service Director Mon State Dr. Zaw Min Htun State Public Health Director Mon State Dr. Mi Thuzar Hlaing Assistant Director Mon State Dr. Nyein Saint Deputy Director Mon State XII

17 4. Dr. Thar Htun Kyaw Deputy Director General (Department of Medical services) Yangon Region Dr. Aye Ko Ko Regional Public Health Director Yangon Region Dr. Aye Myint Zu Assistant Director, Regional Public Health Department Yangon Region Dr. Aye Thandar Win Assistant Director, Regional Public Health Department Yangon Region 5. Dr. Hla Htun Department of State Medical Services Kayah State Dr. Khin Maung Yin State Public Health Director Kayah State Daw Nobel Lynn Township Health Nurse Kayah State Dr. Win Naing Tun Assistant Medical Superintendent Kayah State 6. Dr. Htin Lynn State Public Health Director Shan (N) State Dr. Deepark State Medical Services Director Shan (N) Dr. Htun Than Oo District Medical Officer Shan (N) U Hein Min Soe HA-1 State Public Health Department Shan (N) 7. Dr. Zaw Lin State Public Health Director Shan (E) State Dr. Zaw Lynn State Medical Service Director Shan (E) State Dr. Win Kyaw Than AS - State Medical services Department Shan (E) U Zaw Win THA - State Public Health Department Shan (E) Daw Maw Maw Win State Public Health Department Shan (E) 8. Dr. Thaung Hlaing State Public Health Director Rakhine State Dr. Shwe Thein State Medical Service Director Rakhine State Dr. Maung Maung Win TMO - State Medical Services Department Rakhine State Dr. Yin Yin Phyu THO - State Public Health Department Rakhine State 9. Dr. Aung Kyaw Htwe Regional Public Health Director Bago Region Dr. Kyaw Shwe Regional Medical Service Director Bago Region Dr. Myat Myat Moe DD - Regional Medical Services Department Bago Region Dr. Thin Thin Hlaing THO - Regional Public Health Department Bago Region 10. Dr. Htun Min State Public Health Director Kayin State Dr. Nay Myo Ohn State Medical Service Director Kayin State Dr. Nan Kyar Khaing Htaw AS - State Medical Services Department Kayin State Dr. Khin Moe Thwe AD - State Public Health Department Kayin State 11. Dr. Kyaw Zaya Regional Public Health Director Thaninthari Region Dr. Myo Thet Regional Medical Service Director Thaninthari Region Dr. Thinzar Myint AS - Regional Medical Services Department Thaninthari Region Daw Thet Thet Kyu NO - Regional Public Health Department Thaninthari Region 12. Dr. Htun Myint Regional Public Health Director Ayeyawady Region Dr. Moe Swe Deputy Director General (Department of Medical services) Ayeyawady Region Dr. Thet Su Mon Regional Public Health Department Ayeyawady Region U Kyaw Tint THA, Regional Public Health Department Ayeyawady Region 13. Dr. Hla Hla Kyi Regional Public Health Director Nay Pyi Taw Council Dr. Thida Hla Deputy Director General (Department of Medical services) Nay Pyi Taw Council Dr. Thida Win State Public Health Department Nay Pyi Taw Council Dr. Kyaw Kyaw Lynn State Medical Services Department Nay Pyi Taw Council 14. Dr. Paw Htun Regional MS/PH Director Magway Region Dr. Pyay Nyein Kyaw AS - Regional Public Health Department Magway Region Dr. Zin Min Phwe AMS - Regional Medical Services Department Magway Region U Khaing Tun THA - Regional Public Health Department Magway Region XIII

18 15. Dr. Soe Oo State Public Health Director Shan (South) Dr. Soe Htun Aung MS - State Medical Services Department Shan (South) Dr. Nan Mar Leng Seng AD - State Public Health Department Shan (South) 16. Dr. Kyi Lwin State Public Health Director Chin State Dr. Tin Hla State Medical Service Director Chin State Dr. Joe Set Ban Bwe Oate THO - Regional Public Health Department Chin State 17. Dr. Aung Ngwe San State Medical Service Director Kachin State Dr. Win Lwin State Public Health Director Kachin State Dr. Tin Tin Nyo DMO - State Medical services Department Kachin State Dr. Aung Naing Wynn AD- State Public Health Department Kachin State U Win Aung Maw State Public Health Department Kachin State Field enumerators by assigned states/regions 1. U Win Htay Hlaing Research Assistant, DMR (POLB) Kachin State 2. Daw Nilar Moe Khaing Research Assistant, DMR (POLB) Shan State (South) 3. U Hlaing Lian Moung Research Assistant, DMR (POLB) Shan State (North) 4. Daw Khine Lin Research Assistant, DMR (POLB) Mon State 5. Daw Myint Khin Research Assistant, DMR (POLB) Kayin State 6. Daw Phyu Khine Research Assistant, DMR (POLB) Chin State 7. Daw Malar Aung Research Assistant, DMR (POLB) Thaninthari Region 8. U Min Htuk Kyaw Research Assistant, DMR (POLB) Nay Pyi Taw Council 9. Daw Moe Thandar Research Assistant, DMR (POLB) Bago Region 10. U Thura Ko Lab Attendant, DMR (POLB) Kayah State 11. U Kyaw Wai Research Assistant, DMR (POLB) Shan State (North) 12. U Bo Lynn Lab Attendant, DMR (POLB) Bago Region 13. Daw Thi Htun Research Assistant, DMR (POLB) Ayeyawady Region 14. Daw Moe Thandar Research Assistant, DMR (POLB) Magway Region 15. U Thura Ko Ko Lab Attendant, DMR (POLB) Sagaing Region 16. U Hlaing Lian Moung Research Assistant, DMR (POLB) Sagaing Region 17. Daw Aye Mon San Lab Attendant, DMR (POLB) Mandalay Region 18. U Kyaw Kyaw Wai Research Assistant, DMR (POLB) Rakhine State 19. Daw Aye Myintzu Research Assistant, DMR Yangon Region XIV

19 Field enumerators for client assessment by assigned states/regions 20. Daw Ei Myat Win Shwe PHS-II Mandalay 21. Daw Zune Zune Htun PHS-II Mandalay 22. U Aung Phyo Aye PHS-II Sagaing 23. U Htun Aung Kyaw PHS-II Sagaing 24. U Aye Kyaw San PHS-II Mon 25. U Kaung Htet Lin PHS-II Mon 26. Aung Ko Min PHS-II Yangon 27. U Thura Zaw PHS-II Yangon 28. Daw Kalaw Pyar PHS-II Kayah 29. Daw Poe Myar PHS-II Kayah 30. U Sein Maung PHS-II Shan (N) 31. U Naing Wai Yan lynn PHS-II Shan (N) 32. U Kyaw Thu Win PHS-II Shan (E) 33. U David PHS-II Shan (E) 34. Daw Zin Mar Win PHS-II Rakhine 35. U Ye Win Aung PHS-II Rakhine 36. Daw Sandar Win Pyae PHS-II Bago 37. Daw Moe Lwin PHS-II Bago 38. U Min Zayar Lynn PHS-II Kayin 39. U Saw Nyein Lynn Htun PHS-II Kayin 40. Daw Ei Myo Zin PHS-II Thaninthari 41. U Min Swein PHS-II Thaninthari 42. U Htun Lynn Aung PHS-II Ayeyawady 43. U Kyi Naing PHS-II Ayeyawady 44. U Thein Hteik PHS-II Nay Pyi Taw 45. U Wai Phyo Thu PHS-II Nay Pyi Taw 46. U Hein Latt Oo PHS-II Magway 47. U Htun Naing PHS-II Magway 48. Daw Nan Lu Wyne PHS-II Shan (South) 49. Daw Myat Mon Khaing PHS-II Shan (South) 50. Daw Par Mwe Sone PHS-II Chin 51. Daw Thalae Sone PHS-II Chin 52. U Thet Aung Soe PHS-II Kachin 53. U Aung Zaw Tin PHS-II Kachin XV

20 List of Acronyms BEmOC BS CEmOC CMSD COC CPR DMO DMR-POLB DoPH DMS DPMA ECP EmOC FOC FP GPRHCS HA HF ICT ICPD IEC IUD LHV MCH MIMU MMR MO MRH MS NO ObGy PMTCT RH RHC RHCS (SDGs) SDP THO THN TMO UHC VCT Basic Emergency Obstetric Care Birth Spacing Comprehensive Emergency Obstetric Care Central Medical Store Depot Combined Oral Contraceptive Pill Contraceptive Prevalence Rate District Medical Officer Department of Medical Research (Pyin Oo Lwin Branch) Department of Public Health Department of Medical Services Depo Medroxyprogesterone Acetate Emergency Contraceptive Pill Emergency Obstetric Care Free-of-charge Family Planning Global Programme to Enhance Reproductive Health Commodity Security Health Assistant Health Facility (Service Delivery Point) Information and Communication Technology International Conference on Population and Development Information, Education and Communication Intrauterine Device Lady Health Visitor Maternal and Child Health Myanmar Information Management Unit Maternal Mortality Ratio Medical Officer Maternal and Reproductive Health Medical Superintendent Nursing Officer Obstetrics and Gynaecology Prevention of Mother to Child Transmission Reproductive Health Rural Health Centre Reproductive Health Commodity Security Sustainable Development Goals Service Delivery Point (Health Facility) Township Health Officer Township Health Nurse Township Medical Officer Urban Health Centre Voluntary Counselling and Testing XVI

21 Executive summary Introduction A nationwide survey of a representative sample of health facilities across public health services in all states and regions of Myanmar has been undertaken since 2014 to track Reproductive Health Commodity Security (RHCS) indicators, such as the availability of reproductive health (RH) commodities; the supply chain (including cold chain systems); staff training and supervision; availability of guidelines and protocols; information and communication technologies; methods of waste disposal; and user fees. The surveys have also obtained the views of clients about the quality and cost of services through exit interviews. This is the third report for Myanmar, which is an assessment of the situation in Method A cross-sectional descriptive design with a representative sample size and sampling methods was used covering all states/regions. The standardized questionnaire was adapted and translated. The Department of Medical Research (Pyin Oo Lwin Branch) primarily carried out data collection activities with the assistance of the Department of Public Health and the Department of Medical Services. A total of 378 health facilities were surveyed including 172 at the primary level; 160 at the secondary level; 23 at the tertiary level; and 23 private hospitals. Out of the 358 facilities surveyed; 155 were located in urban areas and 223 were in rural areas. Facilities offering modern contraceptives Survey findings revealed that at primary service delivery points/health facilities (HFs), 81.4 per cent offered at least three modern contraceptive methods. For secondary and tertiary level HFs and private hospitals, 49.5 per cent offered at least five modern contraceptives. The difference in the proportion of HFs that provided five modern methods in government and private sector facilities (45.9 per cent vs per cent) was statistically significant. (P=0.006). Availability of Maternal and RH (MRH) medicines Overall 52.9 per cent of HFs had (at the time of the survey) all seven MRH medicines available, including the two essential life-saving maternal and RH drugs. Urban/rural differences were significant (65.2 per cent vs per cent, P<0.001). The availability of life-saving MRH medicine was higher in HFs in the government sector compared to the private sector (52.1 per cent vs per cent, P=0.139). With the exception of oral misoprostol and injectable benzyl penicillin, all other RH medicine stock-out situations had decreased in 2016 compared to the previous two assessments. Incidence of no stock-out of modern contraceptive methods No stock-out of a modern contraceptive was defined in this study if a HF had a stock of all modern contraceptive methods (excluding male sterilization which a HF is not legally authorized to provide for contraceptive purposes). If a HF had experienced a stock-out or was not able to provide any one modern method of contraception (such as male/female condoms, OCPs, injectables, ECPs, IUDs, implants, female sterilization) in the last six months, it was defined as a stock-out. The findings show that 25.7 per cent of HFs covered in this study were able to provide at least one modern contraceptive method during the last six months. There was no obvious differential among different level of HFs. The stock situation on the day of the assessment showed that OCPs, male condoms, injectables and ECPs were available in all states/regions. Stock-outs of implants and female condoms were highest (on the day of the assessment). Except for stocks of implants, ECPs, IUDs and female sterilization which were higher in urban than rural HFs, no other differences were found with other methods. XVII

22 The rate for stock-out of at least one method was higher for primary level HFs and the total of all HFs in 2016 compared to 2015 and A comparison of the specific methods between the two previous assessments found that there was a reduction in the stock-outs of implants, male condoms, female condoms and injectable methods. No difference for OCPs was noted. Stock-outs for female sterilization had increased. Supply chain including cold chain Pharmacists, Assigned MOS and MS were the main persons responsible for drug indents. Supplies for the majority of primary and secondary level HFs were quantified by the medical depot only (63.8 per cent and 75 per cent respectively). Tertiary level HFs quantified stocks in various ways, i.e. sometimes by themselves and sometimes by the medical depot. The main source of supplies for HFs at all levels were township and state/region Health Departments, 59 per cent and 18.8 per cent respectively. However, supplies for the majority of tertiary level HFs were from the CMSD and state/region Health Departments (43.5 per cent and 39 per cent respectively). The main sources of supplies for private sector HFs were private pharmacies and companies. Major suppliers for HFs in urban areas were state/region Health Departments (HDs) and township HDs (37.4 per cent and 29.7 per cent respectively). The major supplier for HFs in rural areas were township Health Departments (79.4 per cent). Most HFs (>50 per cent) at all levels made their own arrangements for transportation of supplies to their HFs. Transportation of supplies by government to tertiary and secondary level HFs were only 26.1 per cent and 13.1 per cent respectively. The majority of HFs, especially at the primary and secondary level, stated that the interval between the order and receipt of supplies was irregular (42.5 per cent and 41.3 per cent respectively) per cent of HFs at the tertiary level estimated that the interval was less than two weeks. About one third of HFs at all levels stated that the interval was irregular. The percentage of HFs with irregularity of interval was significantly different between HFs in urban and rural areas (38.1 per cent in urban areas vs per cent in rural areas, P<0.05). The majority of private HFs (56.5 per cent) received drug supplies in a relatively short interval (less than two weeks). Thirty five per cent of HFs said that the interval between indents of supplies was irregular. The irregularity was more pronounced in private HFs (73.9 per cent). The frequency of the irregularity of resupply in government sector HFs was similar at all levels (around 35 per cent). The frequency of the irregularity of resupply was more pronounced in private HFs (70.9 per cent vs per cent). The availability of a cold chain (62.7 per cent) was higher in tertiary and secondary level HFs (95.7 per cent and 81.9 per cent respectively) and too a much lesser extent in primary level HFs (35.5 per cent). The difference was statistically significant (P<0.05). All private HFs had cold chain systems. The availability of a cold chain system was also markedly different between urban and rural areas (82.6 per cent vs per cent, P<0.001). While 60.3 per cent of government sector HFs had cold chain systems, in private sector HFs this figure was 100 per cent (P<0.05). Where HFs had a cold chain system, more than 80 per cent were electrical and less than 20 per cent were ice boxes. XVIII

23 Staff training and supervision About 55 per cent of HFs had trained staff to advise clients on birth spacing, which was less than the figure in the 2015 assessment (66 per cent). HFs with trained staff to insert implants was still low (15.6 per cent), again less than last year (17 per cent). Private sector HFs also had low levels of trained staff both to advise clients on birth spacing and to insert implants (47.8 per cent and 52.2 per cent respectively). HFs who had no supervision for RH issues was 32.8 per cent; it was highest in tertiary level HFs (60.9 per cent). The percentage had slightly decreased from last year (44 per cent). The percentages of HFs which had no supervision for RH issues did not differ between urban and rural areas. Private sector HFs had more frequent supervision compared to the government sector. The percentage of HFs which were more frequently visited was higher in rural HFs. One annual visit was higher in urban areas. Supervision for RH issues was more apparent and frequent in government sector HFs than private sector HFs. Supervision in specific areas was described. The most frequent supervision was identified in the area of logistics, followed by staff training, clinical management and reporting. Specific areas of supervision did not differ between levels of HFs. Supervision for following guidelines and instructions was also very notable in this year s assessment. Availability of guidelines, checklists and job aids The availability of any guidelines was not more than 44.2 per cent. Based on all 378 HFs assessed, the most frequently available guidelines were the Job aid for antenatal care (32.3 per cent) and the Guidebook for antenatal care (24.9 per cent). Regarding guidelines for birth spacing, 23.8 per cent of HFs had the Checklist for Birth Spacing. The National Guidebook for Birth Spacing was only available at 15.3 per cent of HFs. The Guide for Waste Disposal was only available at 8.5 per cent of HFs. Use of information and communication technology (ICT) 67.2 per cent of HFs had at least one ICT device. The three devices most frequently used were smart phones (84.4 per cent), mobile phones (53.2 per cent) and computers (31 per cent). It was noted that private sector HFs more frequently had all of the ICT equipment available. ICT devices were most frequently used for routine communication (92 per cent), consultations (34.1 per cent), medical indents (52.5 per cent) and health education (34.3 per cent). Waste disposal Burying and burning were the methods mainly used for waste disposal. However, 56 per cent of HFs at the tertiary level and 82.6 per cent of private HFs used a municipal disposal system. This was more evident in urban HFs than rural HFs (35.5 per cent vs. 2.2 per cent). User fees User fees were reported for 31.4 per cent of HFs. Respondents from 23 per cent of HFs stated there were user fees especially for medicines (25.9 per cent) and speciality services (16.4 per cent). Only 7.7 per cent of HFs charged for consultation fees only. The comparatively higher number of HFs who charged fees was due to the inclusion of private sector HFs in the analysis. Private sector HFs had no free of charge services. Client s perception of family planning service provision Clients were generally satisfied with the quality of services from family planning providers. Favourable responses for the location of the clinic were high (>95 per cent). Most clients were satisfied about the cleanliness and privacy at their health centre. Long waiting times at health centres were reported by XIX

24 less than 15 per cent of respondents. Long waiting times were reported more frequently by clients of tertiary level HFs (33.3 per cent vs per cent (secondary) and 15.8 per cent (primary)). Client s appraisal of cost of family planning services About one third (29.7 per cent) of clients responded they had to pay for services at HFs. The response was highest at the tertiary level (43.5 per cent) and lowest at the primary level (25.3 per cent). The urban/rural difference was significant (36.7 per cent vs per cent, P<0.001). Out of 330 clients who reported they had to pay to visit a clinic, the average amount for various items/services was not more than 600 kyats (i.e. about 0.50 USD). The highest costs incurred were to buy medicine from the clinic or outside of the clinic (512 kyats and 588 kyats). The amount was highest at the secondary level than at any other level (656 Kyats). The total time spent per clinic visit was about 42 minutes on average. This included 15 minutes travel time, and 27 minutes waiting time. Of those clients who visited the clinic during their working day (52.7 per cent), farm workers lost around 3,100 kyats in wages, while sales persons lost approximately 2,000 kyats. Payment to visit the clinic was made primarily by a spouse (66.4 per cent) or by the client themselves (31.6 per cent). XX

25 Recommendations A. Commodities security A1. Contraceptives Secondary level HFs should focus on procuring sufficient contraceptive supplies to meet client demand and choice. A2. RH Medicine RH medicines with high stock-out rates included hydralazine and M-dopa. Health staff in primary level HFs should have their capacity strengthened so that they can use essential MRH medicines safely. A3. Supply Chain Due to continuous efforts, improvements in the supply chain management system were noted from the previous year. However, improvements are still needed at primary level HFs in management, especially in quantifying demand. Distribution systems also need to be reviewed so that they are systematic and effective at the country/state/region level. Distribution methods to primary level HFs should be reviewed so that there is a shorter interval in the delivery of supplies from townships to health centres. A supply of cold chain equipment for primary level HFs should be considered. A system to quantify RH commodity needs should be initiated across the country. B. Contraceptive services Increasing use of implants at secondary level HFs indicates the need for improving the method-mix of contraceptives and also providing more training for staff so that they have the skills to administer longacting contraceptive methods, including implants. C. Logistic and Supply Chain Management System C1. Training Training to improve skills in logistic management should continue and its coverage should be expanded based on programme needs in terms of geographical area and the level of HFs. The areas which have higher stock-outs should be prioritized for training sessions. Effective training to administer implants should be a focus at secondary level HFs especially at Station Hospitals to narrow the urban/rural difference. C2. Supply system Strengthening the supply chain and logistics management should be more comprehensive and take into account the sustainability and self-reliance of state/region Health Departments. The needs of commodities and supplies should be quantified locally. Supply should be changed from a push system into a pull system. Regular quantification of RH commodities, ordering and distribution should be maintained. To reduce stock-outs at all levels of HFs, there should be good channels of reporting and communicating of real-time stock status using modern ICT technology. The feasibility of using mobile phones for realtime reporting of RH logistics should be studied. The role of pharmacists should be systematized in supply chain management at hospitals. XXI